Specific Stop Loss Claims

This type of claim occurs when an employee or dependant has
had medical claims paid by their employer in excess of the amount
specified in the Excess Loss contract.

HOW TO SUBMIT A SPECIFIC STOP LOSS CLAIM

The original claim should be completely processed by the
Administrator, it should be submitted to TPAC after the Specific
Deductible has been exceeded, along with a completed “Specific Claim
Form” (alternate forms may be used if they contain the necessary
information).

TPAC will review the claim and issue any reimbursement payable to
the employer’s benefit fund for the amount that the claim exceeds the
Specific Deductible. All checks will be mailed directly to the
Administrator.

Additional eligible expenses should be accumulated and processed
once a month or when an additional minimum of $500 in expenses has been
incurred, whichever comes first. The Administrator should inform each
employer that such bills will be accumulated and processed in this
manner.

WHAT TO SUBMIT

The entire claim filed with the Administrator should be
submitted. All items must de dated stamped and in chronological order
based on the date the Administrator received the expenses. The claim
file should include a completed claim from which contains an employee
statement. It is recommended that the Administrator receive a completed
claim form at least once every 12 months.

All worksheets completed by the Administrator.

Itemized bills for all expenses. Balance due statements,
cash register receipts and cancelled checks are not eligible for
consideration.

All correspondence, memorandums and telephone messages related to the claim file.

Calculations used for determination of usual and customary fees.

All details regarding investigation of eligibility and coordination of benefits.

Copies of claim checks or drafts issued by the Administrator.

Copies of enrollment Card/Forms with the employee’s original effective date of coverage.

SPECIAL HANDLING, COMMENTS AND RECOMMENDATIONS

Referral should be made to TPAC for advice on medical
management of claims that involve long term and/or large dollar
liabilities.

File documentation is critical. Claims will not be
considered if they are not properly documented with fully completed
claim forms and itemized bills.

All documents must be date stamped when received by the Administrator. All claims should be processed in a timely manner.

TPAC must be advised in writing as soon as possible of any
law suit in which they are named or could become involved because of
Excess Loss Coverage.